Tobacco Company Campaign Contributions and Congressional Support of Tobacco Legislation

Richard A. Robbins, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ USA

Abstract

Although it is widely held that campaign contributions influence Congressional support for legislation, the impact of these contributions is unclear. Three bills involving tobacco regulation were introduced into the 2017-8 Congress and were co-sponsored in both the House of Representatives and Senate. One was pro-tobacco (HR564/S294-Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017) and two were anti-tobacco (HR4273/S2100-Tobacco to 21 Act, HR2878/S1341-Children Don't Belong on Tobacco Farms Act). The association between tobacco political action committee (PAC) campaign contributions with sponsorship of these bills was examined. Tobacco PAC contributions to sponsors of pro-tobacco HR564/S294 were significantly larger [$18218, 95% confidence interval (CI) $15077-$21359, p<0.01] than to non-sponsors ($8730, 95% CI, $6959-$10501). Sponsors of the anti-tobacco HR4273/S2100 received significantly smaller contributions ($2114, 95% CI $0-$4833, p<0.01) than non-sponsors ($12048, 95% CI, $10289-$13707). Similarly, sponsors of the anti-tobacco HR2878/S1341 also received significantly smaller contributions ($2500, 95% CI $0-$5284, p<0.01) than non-sponsors ($12097, 95% CI $10429-$13765). These data demonstrate a significant correlation between campaign contributions and legislative support of pro- and anti-tobacco legislation.

Introduction

Previously, it has been shown tobacco contributions influence state legislators in terms of tobacco control policy-making and support by Southwest US Members of Congress of The Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2015 (HR 662/S 441, aka the "Cigar Bill") (1,2). Although it is widely held that campaign contributions influence elected legislators, Powell (3) notes "political scientists have had great difficulty determining whether and how much influence contributions have on the legislative process". Studies have been inconsistent, with some demonstrating a linkage between campaign contributions and influence while others do not, suggesting that there are other influences in addition to contributions. Powell (3) has pointed out that the influence of donations is likely to occur early in the legislative process, such as during sponsorship for legislation or by directing that funds should be spent on a specific project (earmarks).

During the current 115^th Congress, the pro-tobacco “The Traditional Cigar Manufacturing and Small Business Jobs Preservation Act” was reintroduced (HR564/S294) (4). In addition, two anti-tobacco bills were introduced (HR4273/S2100 and HR2878/S1341) (4). Tobacco PAC contributions were examined for their association with sponsorship of these bills.

Methods

Tobacco Bills

The website Congress.Gov (4) was searched with the key word tobacco. Three bills were identified that had reached sufficient maturity to be introduced into the House of Representatives and the Senate and had co-sponsors listed in both the House and Senate. One was the pro-tobacco (HR564/S294-Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017) and two were anti-tobacco (HR4273/S2100-Tobacco to 21 Act, HR2878/S1341-Children Don't Belong on Tobacco Farms Act) (Table 1).

Table 1. Tobacco related legislation introduced during the 115^th session of Congress.

Sponsors and cosponsors were identified as listed on Congress.Gov.

Campaign Contributions

Tobacco company political action committee (PAC) contributions to members of Congress were obtained from the Campaign for Tobacco-Free Kids website (5). Contributions from the years listed (2006-18) were summed and no effort was made to separate recent from more past contributions.

Statistics

The relationship between sponsorship of the tobacco-related bills and tobacco PAC campaign contributions was done by Fisher's exact test using a 2X2 contingency table. Amounts of campaign contributions were expressed as means with 95% confidence intervals. The Mann-Whitney U test was used to calculate comparisons of the amounts of campaign contributions.

Results

Tobacco PAC Contributions

Sixty-five percent of the members of Congress have received a tobacco PAC contribution since 2006 (Appendix 1). The average reported was $11,637. Ten members received over $80,000, of which the largest was to Sen. Richard Burr (R-NC)($124,022); all but three were from what is referred to as the deep South. Over $6 million was donated in total; 82% of the donations went to Republicans.

Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017 (HR564/S294)

Ninety-four percent of the members of Congress who cosponsored the pro-tobacco "Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017 (aka Cigar Bill)" had received tobacco PAC campaign contributions (Appendix 2). In contrast, 53% of who were not cosponsors had received contributions (p<0.01 by Fisher's Exact Test). Furthermore, the amount of contributions was larger for those who had cosponsored the bill larger ($18218, 95% CI $15077-$21359) than non-sponsors ($8730, 95% CI, $6959-$10501, p<0.01 by Mann-Whitney U test).

Tobacco to 21 Act (HR4273/S2100)

Eighty-two percent of the members of Congress who cosponsored the anti-tobacco " Tobacco to 21 Act" had not received tobacco PAC campaign contributions (Appendix 3). In contrast, 35% of who were not cosponsors had not received contributions (p<0.01 by Fisher's Exact Test). Furthermore, the amount of contributions was smaller for those who had cosponsored the bill ($2114, 95% CI $0-$4833) than non-sponsors ($12048, 95% CI, $10289-$13707, p<0.01 by Mann-Whitney U test).

Children Don't Belong on Tobacco Farms Act (HR2878/S1341) 

Data were similar with the anti-tobacco “Children Don't Belong on Tobacco Farms Act”. Seventy-eight percent of the members of Congress who sponsored the bill had not received tobacco PAC campaign contributions (Appendix 4). Thirty-five percent of the members of Congress who had not cosponsored the bill did not receive contributions (p<0.01 by Fisher's Exact Test). Furthermore, the amount of contributions was smaller for those who had cosponsored the bill ($2500, 95% CI $0-$5284) than non-sponsors ($12097, 95% CI $10429-$13765), p<0.01 by Mann-Whitney U test).

Discussion

This manuscript shows an association between tobacco PAC campaign contributions and sponsorship of both pro- and anti-tobacco legislation. More members of Congress who supported the pro-tobacco “Traditional Cigar Manufacturing and Small Business Jobs Preservation Act of 2017” had received tobacco PAC campaign contributions and the contributions were larger compared to those not sponsoring the legislation. The data was the opposite for the anti-tobacco “Tobacco to 21 Act” and “Children Don't Belong on Tobacco Farms Act”. The percentage of the members of Congress who had not received tobacco PAC contributions was higher for those who sponsored the legislation compared to those who did not. Taken together these data suggest an influence of campaign contributions on the sponsoring of tobacco legislation in the US Congress.

The data in this manuscript confirms and extends the previous observations that tobacco contributions to state legislators and Southwest Members of Congress influence support of tobacco legislation (1,2).  The Southwest US is not a major tobacco growing or manufacturing region (7). Furthermore, tobacco consumption tends to be low in Southwest US (7). The Southwest is a good area to study the influence of campaign contributions because of the lack of confounding influences from a constituency that makes a living by tobacco growing or manufacturing or has a high prevalence of smokers. Reexamination of the correlation between tobacco PAC contributions and Congressional sponsorship of the "Cigar Bill" shows similar results with the data in 2016 (1, Appendix 1). The present study shows that association occurred in Congress as a whole and extended to anti-smoking legislation.

The title of HR564/S294 is deceiving. The “Traditional Cigar Manufacturing and Small Business Jobs Preservation Act” is titled to conjure up images of small businesses hand-rolling premium cigars. However, many of the cigars affected by the legislation are not the large, thick, and expensive ones manufactured with fine tobacco but rather small, thin, cheap cigars that are often flavored (8).

There is no doubt that smoking tobacco is harmful including cigars where the risk can be as high as or exceed those of cigarette smoking (9). Cigarette consumption in the United States is decreasing, compelling US tobacco companies to search for new markets (10). The cigar market, especially the flavored cigar market, represents one strategy to increase tobacco consumption and profits. Flavored cigar use is increasing in US middle and high school students (11). Therefore, tobacco companies support of the "Cigar Bill" is not surprising. By removing regulation, the tobacco companies can increase advertising to children and grow the candy-flavored cigar market (8).

The amount of money donated by the tobacco PACs is quite large and would seem to exceed anything that anti-tobacco smoking organizations could muster. Sixty-five percent of the members of Congress have received contributions totaling over 6 million dollars since 2006. The influence of these contributions may make regulation of tobacco quite difficult.

This manuscript has several limitations. Receiving tobacco PAC contributions and sponsoring pro-tobacco legislation does not necessarily represent cause and effect. It seems likely that tobacco companies would be more likely to support legislators that they perceive as sympathetic. It also seems likely that the tobacco PACs would be less likely to donate to supporters of anti-tobacco legislation.

References

1. Monardi F, Glantz SA. Are tobacco industry campaign contributions influencing state legislative behavior? Am J Public Health. 1998 Jun;88(6):918-23. [CrossRef] [PubMed]
2. Robbins RA. Tobacco company campaign contributions and congressional support of the cigar bill. Southwest J Pulm Crit Care. 2016;13(4):187-90. [CrossRef]
3. Powell LW. The influence of campaign contributions on legislative policy. The Forum: A Journal of Applied Research in Contemporary Politics 2013;11(3):339-55. [CrossRef]
4. Congress.gov. Available at: https://www.congress.gov/ (accessed 3/26/18).
5. Campaign for Tobacco-Free Kids. Tobacco company political action committee (PAC) contributions to Federal candidates. Available at: https://www.tobaccofreekids.org/what-we-do/us/tobacco-campaign-contributions  (accessed 3/26/18).
6. Statistica. Statistics and facts about the tobacco industry. Available at: http://www.statista.com/topics/1593/tobacco/ (accessed 3/26/18).
7. Campaign for tobacco-free kids. Key state-specific tobacco-related data & rankings. Available at: https://www.tobaccofreekids.org/assets/factsheets/0176.pdf (accessed 3/26/18).
8. American Thoracic Society. ATS Joins Letter Opposing Cigar Exemption. October, 2017. Available at: https://news.thoracic.org/washington-letter/2017/ats-joins-letter-opposing-cigar-exemption.php (accessed 3/26/18).
9. Chang CM, Corey CG, Rostron BL, Apelberg BJ. Systematic review of cigar smoking and all cause and smoking related mortality. BMC Public Health. 2015 Apr 24;15:390. [CrossRef] [PubMed]
10. Centers for Disease Control. Current Cigarette Smoking Among Adults in the United States. Available at: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/index.htm (accessed 3/26/18).
11. King BA, Tynan MA, Dube SR, Arrazola R. Flavored-little-cigar and flavored-cigarette use among U.S. middle and high school students. J Adolesc Health. 2014 Jan;54(1):40-6. [CrossRef] [PubMed]

Cite as: Robbins RA. Tobacco company campaign contributions and congressional support of tobacco legislation. Southwest J Pulm Crit Care. 2018;16(4):232-6. doi: https://doi.org/10.13175/swjpcc053-18 PDF 

Social Media: A Novel Engagement Tool for Miners in Rural New Mexico

Shreya Wigh¹

William Cotton Jarrell, CMSP³

Elizabeth Kocher, MPH¹

Roger Karr²

Xin Wang, MS¹

Akshay Sood, MD, MPH^1,2

¹University of New Mexico Health Sciences Center School of Medicine

Albuquerque, NM, USA

²Miners Colfax Medical Center

Raton, NM, USA

³Peabody New Mexico Services

Grants, NM, USA

Abstract

Background: New Mexico miners usually live in rural areas. As compared to urban areas, rural areas in the United States demonstrate a lower use of the Internet and lower adoption of new technologies such as the smartphone and social media. Our study objective was to examine the use of these technologies among miners in rural New Mexico. Our long-term goal is to utilize these technologies to increase our program’s engagement with miners to provide medical screening and education services. Methods: We anonymously surveyed 212 miners at two town hall meetings in rural New Mexico communities, predominantly Hispanic and American Indian, in 2017. We then compiled that data in a Research Electronic Data Capture (REDCap) database and performed a statistical analysis using Statistical Analysis Software (SAS). IRB approval was obtained. Results: 60.8% of the 212 surveyed miners reported using social media. Among social media users, 88.4% reported using Facebook.  Most miners expressed willingness to use social media to keep in contact with other miners (51.2% overall) or to receive information about our miners’ program services (53.9% overall); and social media users were more likely to do so than non-users (p<0.001 for both analyses). Additionally, 79.7% of miners who owned a smartphone utilized it for texting. Conclusions: A majority of miners in rural New Mexico report use of social media and express willingness to use social media to network with other miners and with our program. The adoption of these communication technologies by rural New Mexico miners in our study is comparable or superior to that reported by rural Americans overall. It is possible to utilize this newer technology to increase program engagement with miners.

Introduction

New Mexico miners usually live in rural and medically underserved areas and suffer from multiple chronic diseases, particularly dust related lung diseases or pneumoconiosis. Rural counties in northern New Mexico have among the highest mortality rates for silicosis and pneumoconiosis, including coal workers’ pneumoconiosis, in the United States (1). To address this challenge, Miners’ Colfax Medical Center and the University of New Mexico have partnered in a federally funded medical screening program for rural miners.  As compared to urban areas, those who live in rural areas reportedly have a lower use of the Internet and are less willing to adopt new communication technologies such as the smartphone and social media (2). We have previously published that the primary source of information about miners’ health related activities for attendees at our miners’ health screening programs are traditional routes of communication such as a relative, friend, and community newspaper or flyer (3). Traditional media is, however, a one-way communication system that doesn’t create program engagement or work towards promoting word-of-mouth - the hallmark of social media (4). Our programs could utilize social media to promote awareness, encourage miner engagement, and increase the spread of accurate health messaging among New Mexico miners. Serving older, less educated, poorer, racial/ethnic minority, miners living in geographically remote and medically underserved rural areas of New Mexico may however affect the use and effectiveness of this communication tool.

The objective of our study was to examine the use of Internet-based smartphone and social media technology among miners in rural New Mexico. We hypothesized a low usage rate of these novel communication technologies among rural miners in New Mexico. Our long-term goal is to use these technologies to increase bidirectional engagement with miners with our federally funded Black Lung and Radiation Exposure Screening and Education Programs that currently provide medical screening, health care, and education services to coal and uranium miners in New Mexico.

Methods

Study design: This is a cross sectional survey of 212 miners, mostly coal miners, at two town hall meetings held in rural and medically underserved communities of Grants and Socorro, New Mexico, in 2017. These communities are predominantly American Indian and Hispanic respectively. The town hall meetings were held in conjunction with mobile health screening clinics for miners.

Survey creation: We created a survey on the use of the smartphone and social media, which asked construct-specific questions with either Yes/No responses or multiple choices. Examples of questions included whether miners would be willing to use social media to stay in touch with the mining community and if they had access to a computer with internet. The questions were formatted for an eighth-grade vocabulary, since our previous studies have shown that 57.2% of New Mexico miners do not complete high school education (3).

Survey administration: The paper copy of the survey was given to miners to fill out during the town hall meeting by the mine safety officer, on a voluntary and anonymous basis.

Analytic and database strategy: We compiled the survey data into a Research Electronic Data Capture (REDCap) database. We compared characteristics between social media users with social media non-users. Statistical analysis included an analysis of frequency distributions and Chi-square test, using Statistical Analysis Software (SAS 13.0, Cary, NC). A p-value less than 0.05 was considered statistically significant. We obtained human Institutional Review Board (IRB) approval for research exempt status (HRPO 14-058). The study was sponsored by Health Resource Services and Administration (HRSA) and Patient Centered Outcomes Research Institute (PCORI).

Results

60.8% of the 212 miners surveyed reported using social media. Among the social media users, 88.4% reported using Facebook, 27.9% reported using Instagram, and 26.4% reported using Snapchat.  Social media users reported utilizing the technology for an average of 47.9 ± 134.3 (SD) minutes daily, for approximately 6.0 ± 4.4 (SD) years. Most miners expressed willingness to use social media to keep in contact with other miners (51.2% overall) or to receive information about our miners’ program services (53.9% overall); and social media users were more likely to do so than non-users (p<0.001 for both analyses, Table 1).

Table 1. Difference in characteristics between self-reported social media users and nonusers, among rural miners in New Mexico.

86.3% of the miners surveyed also reported possessing a smart phone (93.8% versus 74.7% of the social media users and non-users respectively; p<0.001). 79.7% of miners owning a smartphone utilized it for texting (91.5% versus 61.5% of social media users versus nonusers respectively; p<0.001).

94.3% of rural miners reported having access to the Internet. Social media users were more likely to report having Internet access via computer or via phone than non-users (p = 0.08 and <0.001 respectively, Table 1). 24.0% of all miners however reported poor Internet connection as a challenge, and as compared to nonusers, social media users were more likely to report this challenge (p=0.01). 13.2% of all miners complained of the high expense of the Internet and the social media user status did not predict this characteristic (p=0.67). There was also no difference between the two groups with respect to the reported difficulty in navigating social media sites (p=0.32).

Discussion

Based on our results, we conclude that the majority of miners in rural New Mexico use Internet-based smartphone and social media technologies and are willing to use social media to network with other miners or programs that deliver health services to miners. We found that Facebook was the most popular social media site. The adoption of these communication technologies by rural New Mexico miners in our study is comparable or superior to that reported by rural Americans overall. This suggests that it is possible to use smartphone texting and social media technology to increase bidirectional program engagement with miners in rural New Mexico.

In 2017, the proportion of US population with a social media profile was variably estimated at 69-81% (5-7). Rural Americans in the US were approximately 8% less likely to use social media than urban Americans (2). The market leader in social media was Facebook, used by 68% and 79% of all and online American adults respectively (7). In our study, 60.8% of the rural miners reported using social media and 53.8% reported using Facebook, which is comparable to that reported in other US rural communities. In 2017, the proportion of American adults who owned a smartphone was 83%, 78%, and 65% for urban, suburban, and rural locations respectively (8). In comparison, 86.3% of rural miners in our study reported possessing a smartphone, indicating a higher level of smartphone possession than that reported by rural Americans overall. In 2017-2018, 89% of all American adults used the Internet (9). In an earlier survey from November 2016, 81% of rural Americans used the Internet, as compared to 89% of urban Americans (10). 63% of rural Americans had a broadband Internet connection at home, 10 percentage points less likely than Americans overall (10). In comparison, 94.3% of rural New Mexico miners in our study reported having access to the Internet, indicating a higher level of Internet access than that reported by rural Americans overall. Contrary to our initial hypothesis, we found that rural New Mexico miners in our study reported adoption of newer communication technologies at a level that was comparable or superior to that reported by rural Americans overall.

Racial/ethnic and health status-related disparities exist with respect to Internet access in the U.S. (9). However, among those with Internet access, these characteristics do not affect their social media use (11). New Internet-based technologies including smartphone and social media, may be changing the communication pattern throughout the U.S. and the world but this change has not been well studied, particularly in rural areas (11).  Potential overarching benefits of social media for health communication are (1) increased interactions with others, (2) more available, shared, and tailored information, (3) increased accessibility and widening access to health information, (4) peer/social/emotional support, (5) public health surveillance, and (6) potential to influence health policy (12). Our findings indicate that social media can similarly be used for health communication purposes among rural miners in New Mexico. Our HRSA-funded miners’ health and benefits programs in New Mexico have established a social media platform to provide rural miners with information on our clinical programs, research, education and other interventions as well as to provide opportunities for bidirectional engagement between the program and miners as well as among miners themselves. Our program has also launched a social media literacy campaign for miners, with the help of a rural mine safety officer.

Currently there is a limited amount of literature evaluating the use of social media for sustained engagement of diverse communities in health promotion (13,14). For instance, the Youth Voices Research Group has reported creating novel opportunities to engage young people to explore health topics ranging from tobacco use, food security, mental health, and navigation of health services, by combining social organizing with arts-informed methods for creative expression, using information technology (14). Creating opportunities for engagement alone is however insufficient. The information exchanged needs to be monitored for quality and reliability, users’ confidentiality and privacy need to be maintained (12), and its impact evaluated. Use of social media in health promotion in underserved populations, such as indigenous populations in Australia, is associated with limited evidence of benefit (15). Online social network health behavior interventions are reported to have small effect sizes, often statistically nonsignificant, with high participant attrition and low fidelity (16). It is therefore necessary for our program to critically evaluate the role and effectiveness of these new technologies in health promotion and health care for our population of rural miners.

The strength of our study includes inclusion of miners from rural and predominantly Hispanic and American Indian communities. Limitations of our study include small sample size and lack of information on individual demographic characteristics. Although our study was limited to New Mexico, our findings may be generalizable to other rural and medically underserved areas of the United States outside of New Mexico.

Conclusions

Most miners in rural New Mexico have Internet access, use smartphones and social media, and are willing to use social media to network with other miners or programs that deliver health services to miners. Rural New Mexico miners in our study report adoption of newer communication technologies at a level that is comparable or superior to that reported by rural Americans overall. This study provides preliminary information on a potential and novel way in which rural mining communities and miners’ health and benefits programs can engage with each other to promote miners’ health by assisting in clinical programs, research, education and other interventions. Miners’ program may consider interactive blogging, photograph elicitation, and video documentaries, alongside real-world social media projects, to promote this engagement. Potential barriers in rural miners include low social media literacy and poor Internet connection. Low social media literacy can however be addressed by targeted education of miners. Emerging areas of research include evaluating the effectiveness of the use of smartphones and social networking platforms such as Facebook, in building effective interventions for health promotion and providing healthcare for miners in rural communities.

Acknowledgments

SW, WCJ, EK, RK, KW, AS made substantial contributions to the conception or design of the work; SW, WCJ, EK, RK, KW, AS made substantial contributions to the acquisition, analysis, or interpretation of data for the work. SW, WCJ, EK, RK, KW, AS made substantial contribution towards drafting the work or revising it critically for important intellectual content. SW, WCJ, EK, RK, KW, AS provided the final approval of the version to be published. SW, WCJ, EK, RK, KW, AS agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

References

1. Dwyer-Lindgren L, Bertozzi-Villa A, Stubbs RW, et al. Trends and Patterns of Differences in Chronic Respiratory Disease Mortality Among US Counties, 1980-2014. JAMA. 2017;318(12):1136-49. [CrossRef] [PubMed]
2. Perrin A. Social Networking Usage: 2005-2015. Pew Research Center. 2015. Available at: http://www.pewinternet.org/2015/10/08/2015/Social-Networking-Usage-2005-2015/, last accessed on March 28, 2018.
3. Evans K, Lerch S, Boyce TW, et al. An innovative approach to enhancing access to medical screening for miners using a mobile clinic with telemedicine capability. J Health Care Poor Underserved. 2016;27(4A):62-72. [CrossRef] [PubMed]
4. Hausman A. Social media versus traditional media. 2014. Available at https://www.hausmanmarketingletter.com/social-media-versus-traditional-media/, accessed on January 9, 2018.
5. Statistica – The Statistics Portal. Percentage of U.S. population with a social media profile from 2008 to 2017. 2018. Available at https://www.statista.com/statistics/273476/percentage-of-us-population-with-a-social-network-profile/, accessed on March 28, 2018.
6. Perrin A. Social Media Fact Sheet. Pew Research Center. 2018. Available at: http://www.pewinternet.org/fact-sheet/social-media/, last accessed on March 28, 2018.
7. Perrin A. Social Media Update 2016. Pew Research Center. 2016. Available at: http://www.pewinternet.org/2016/11/11/social-media-update-2016/, last accessed on March 28, 2018. 2016.
8. Statistica – The Statistics Portal. Share of adults in the United States who owned a smartphone from 2011 to 2017, by location. 2018. Available at https://www.statista.com/statistics/195003/percentage-of-us-smartphone-owners-by-geographic-location/; accessed on March 28, 2018. 2018.
9. Perrin A. Internet/Broadband Fact Sheet. Pew Research Center. 2018. Available at: http://www.pewinternet.org/fact-sheet/internet-broadband/, last accessed on March 28, 2018.
10. Perrin A. Digital gap between rural and non-rural America persists. 2017. Pew Research Center. Available at: http://www.pewresearch.org/fact-tank/2017/05/19/digital-gap-between-rural-and-nonrural-america-persists/, last accessed on March 28, 2018.
11. Chou WY, Hunt YM, Beckjord EB, Moser RP, Hesse BW. Social media use in the United States: implications for health communication. J Med Internet Res. 2009;11(4):e48. [CrossRef] [PubMed]
12. Moorhead SA, Hazlett DE, Harrison L, Carroll JK, Irwin A, Hoving C. A new dimension of health care: systematic review of the uses, benefits, and limitations of social media for health communication. J Med Internet Res. 2013;15(4):e85. [CrossRef] [PubMed]
13. Yonker LM, Zan S, Scirica CV, Jethwani K, Kinane TB. "Friending" teens: systematic review of social media in adolescent and young adult health care. J Med Internet Res. 2015;17(1):e4. [CrossRef] [PubMed]
14. Norman CD, Yip AL. eHealth promotion and social innovation with youth: using social and visual media to engage diverse communities. Studies in health technology and informatics. 2012;172:54-70. [PubMed]
15. Brusse C, Gardner K, McAullay D, Dowden M. Social media and mobile apps for health promotion in Australian Indigenous populations: scoping review. J Med Internet Res. 2014;16(12):e280. [CrossRef] [PubMed]
16. Maher CA, Lewis LK, Ferrar K, Marshall S, De Bourdeaudhuij I, Vandelanotte C. Are health behavior change interventions that use online social networks effective? A systematic review. J Med Internet Res. 2014;16(2):e40. [CrossRef] [PubMed]

Cite as: Wigh S, Jarrell WC, Kocher E, Karr R, Wang X, Sood A. Social media: A novel engagement tool for miners in rural New Mexico. Southwest J Pulm Crit Care. 2018;16(4):206-11. doi: https://doi.org/10.13175/swjpcc017-18 PDF

April 2018 Pulmonary Case of the Month

Ashely L. Garrett, MD

Mayo Clinic Arizona

Scottsdale, AZ USA

History of Present Illness

A 74-year-old woman with known chronic obstructive pulmonary disease (COPD) presented to emergency department on 2/4/18 with dyspnea. She had been hospitalized at another hospital from 12/29/17 - 1/30/18 for a COPD exacerbation and health care associated pneumonia described as a cavitary pneumonia. She was treated with various doses of systemic steroids and antibiotics. Her course was complicated by atrial fibrillation with a rapid ventricular response. She eventually was discharged to a skilled nursing facility.

Past Medical History, Social History and Family History

She has a known history of COPD with an FEV1 of 22% of predicted and is on 2L/min of O2 by nasal cannula. There is also a history of:

• Hypertension.
• Hypercholesterolemia.
• Paroxysmal atrial fibrillation, not on anticoagulation.
• Right 4 mm PICA aneurysm

She lives in rural Kingman, AZ with some dust and outdoor bird exposure.

Family history is noncontributory.

Medications

• Alprazolam 0.25 mg p.o. b.i.d.
• Symbicort two puffs inhaled b.i.d.
• Diltiazem 120 mg p.o. q.12h
• Disopyramide 150 mg p.o. q.6h
• Furosemide 20 mg p.o. daily
• Levalbuterol 0.31 mg q.6 days p.r.n.
• Meperidine 50 mg p.r.n. pain
• Metoprolol succinate 12.5 mg p.o. b.i.d
• Prednisone 10 mg p.o. daily

Physical Examination

• Vitals: BP 110/65 mm Hg, P 130 irregular beats/min, T 37° C, Respirations 20 breaths/min
• General: Appears in mild respiratory distress
• Lungs: Distant breath sounds
• Heart: Irregular rhythm with distant tones
• Abdomen: no organomegaly, masses or tendernesses
• Extremities:  No edema

Which of the following should be done at this time? (Click on the correct answer to proceed to the second of six pages)

1. Arterial blood gases (ABGs)
2. Chest x-ray
3. Electrocardiogram
4. 1 and 3
5. All of the above

Cite as: Garrett AL. April 2018 pulmonary case of the month. Southwest J Pulm Crit Care. 2018;16(4):174-82. doi: https://doi.org/10.13175/swjpcc050-18 PDF

First-Line Therapy for Non-Small Cell Lung Cancer Including Targeted Therapy: A Brief Review

Richard A. Robbins, MD*

Thomas D. Kummet, MD**

*Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ USA

**Sequim, WA USA 

Abstract

Operative removal of non-small cell lung cancer remains the mainstay of therapy. When this is not possible, cytotoxic chemotherapy and/or radiotherapy can be given but are marginally effective in prolonging overall survival. However, with a better understanding of the pathobiology of the lung cancer cells, new targeted therapies have been developed which may produce dramatic responses in selected patients. This brief review will emphasize these newer therapies in this rapidly evolving field.

Introduction

Lung cancer is extremely common and remains by far the most frequent cause of cancer-related death with approximately 154,050 deaths estimated to occur during 2018 (1). Although lung cancer deaths have declined in men, the deaths have risen in women and now account for nearly half of all women’s cancer deaths (1). Unfortunately, the vast majority are diagnosed with advanced, unresectable disease that remains incurable (1). Overall the five-year survival rate is <1% for advanced (stage IVB) disease, while the five-year survival rate for all stages is approximately 15 % (1).

Data linking cigarette smoking to human lung cancer is incontrovertible (2). The risk increases with both the amount of smoking and the duration of smoking (2). Passive or second-hand smoke is also associated with an increase in the risk of lung cancer, although this increase is far lower than that observed with active smoking (2). Smoking cessation clearly decreases the risk of lung cancer (2).

Primary lung cancers can be divided into two main types based on their histology, small cell lung cancer and non-small cell lung cancer (NSCLC) (3). NSCLC constitute about 85% of lung cancers with the rest consisting of small cell and some rarer cancers (3). A basic understanding of the pathobiology of NSCLC has shown that the tumor cells depend on the formation of new blood vessels (angiogenesis), transfer of a phosphate group from ATP to tyrosine on proteins (tyrosine kinase), and regulation of programmed death ligands (checkpoint proteins) (4). Targeted therapy against these pathobiologic processes have shown dramatic effects in some NSCLC patients (4).

NSCLC is divided into 4 stages designated by roman numerals (5). The stages are based on the size of the tumor; whether it has metastasized locally or distally; and use the TNM classification where T designates tumor size; N regional lymph node metastasis; and M distant metastasis. Stages I and II are limited to the chest but stage III has metastasized to the pleura and/or regional lung lymph nodes. Stage IIIA means the cancer has metastasized to lymph nodes that are on the same side of the chest as the cancer (ipsilateral) while stage IIIB signifies metastasis to lymph nodes on the opposite side of the chest (contralateral). Stage IV denotes there are distant metastasis outside the chest. The above is admittedly an oversimplification and there are subtle nuances that define the stages which can be found at the National Cancer Institute website (5).

An overall summary of standard preferred by the National Cancer Institute for NSCLC by stage is shown in Table 1 (6).

Table 1. Standard preferred therapy for NSCLC by stage (6).

Surgery

Operative removal of the lung cancer is the cornerstone of management for patients with early-stage (stages I–II) NSCLC and selected patients with stage IIIA disease (7). Lobectomy is the operation of choice for localized NSCLC based on a randomized trial of lobectomy versus more limited resection (8). Operative intervention should be offered to all patients with stage I and II NSCLC who clinically are medically fit for surgical resection. However, patients may be unable to undergo a lobectomy for a variety of reasons such as: 1. severely compromised pulmonary function; 2. multisystem disease making lobectomy excessively hazardous; 3. advanced age; or 4. refusal of the operation. Some patients who cannot tolerate a full lobectomy but may be able to tolerate a more limited sublobar operation (6). For patients in whom complete tumor resection cannot be achieved with lobectomy, sleeve lobectomy is recommended over pneumonectomy because it preserves pulmonary function (6). In addition, the question of whether video-assisted thorascopic surgery (VATS) is equivalent to thoracotomy for patients with lung cancer comes up often, particularly in patients that are less than ideal surgical candidates. In a series of 741 patients with stage IA NSCLC, 5-year survival was similar but VATS was associated with fewer complications and a shorter length of hospital stay (9).  Therefore, VATS is an optional surgical approach particularly in poorer risk patients.

Radiotherapy

Although lobectomy is the treatment of choice for NSCLC patients with early-stage disease, some are unable to undergo an operation due to reasons listed above. For those patients, radiotherapy can be administered with curative intent, albeit with lower overall survival rates when compared to surgery (10,11).

The radiation oncology community is excited about the potential of stereotactic body radiation therapy (SBRT) (12,13). SBRT is a type of external radiation therapy that uses special equipment to position a patient and precisely deliver radiation to tumors in the body (except the brain). Although there is no data yet, trials are ongoing comparing SBRT with surgery in early stage NSCLC.

Adjuvant Therapy

Adjuvant chemotherapy. Adjuvant chemotherapy is chemotherapy that is given in addition to either surgical and/or radiation therapy. Data from recent randomized adjuvant clinical trials and a meta-analysis support the use of adjuvant chemotherapy in NSCLC (14). A 5.4% five-year survival benefit was observed in a meta-analysis of five randomized trials compared to observation. Not surprisingly, the survival benefit varied according to stage but the benefit was most pronounced for patients with stage II and IIIA disease. Survival benefit in patients with stage IB disease did not reach statistical significance. Importantly, patients with stage IA disease appeared to do worse with adjuvant chemotherapy, and therefore, is not currently recommended.

Adjuvant radiotherapy. The PORT meta-analysis of 2,128 patients demonstrated that the use of post-operative radiotherapy was associated with a detrimental effect on survival (15,16). The decrease in survival was more pronounced for patients with lower nodal status. The PORT meta-analysis has been criticized for its long enrolment period and use of different types of machines, techniques and radiation doses. Despite these criticisms, three randomized phase III trials support the PORT meta-analysis’ conclusion that the use of post-operative radiotherapy provides no survival benefit (17-19). For patients with N2-positive disease, however, a retrospective analysis demonstrated higher survival for those patients who had received post-operative radiotherapy (20). On the basis of the above studies, most do not recommend routine post-operative radiotherapy with the possible exception of those with N2 disease.

Locally Advanced Disease

About a third of patients with NSCLC present with disease that remains localized to the thorax but may be too extensive for surgical treatment (stage III) (21). Concurrent chemotherapy and radiation therapy is considered the standard therapy for this situation but results in only a modest, although statistically significant, survival benefit compared with sequential administration (21). However, significant toxicity results from this approach and so it is usually offered only to those with good performance status.

Surgery after chemotherapy in patients with N2 disease was tested in two randomized trials. A European trial used three cycles of cisplatin-based chemotherapy, then randomized the patients to surgery or sequential thoracic radiotherapy (22). There was no significant difference in overall survival or progression-free survival. An American trial used a slightly different protocol (23). Patients with N2 disease were given two cycles with concurrent radiotherapy and then randomized to further radiation or surgery. This trial showed a better progression free survival with surgery but no difference in overall survival.

Metastatic Disease

About 40% of patients with NSCLC present with advanced stage IV disease. Until recently, cytotoxic chemotherapy was the cornerstone of treatment for stage IV disease but is now recommended as first line therapy alone only for patients with low or no expression of markers for targeted therapy (24). Unfortunately, in stage IV NSCLC standard cytotoxic chemotherapy alone is minimally effective. A meta-analysis that included 16 randomized trials with 2,714 patients demonstrated that cytotoxic chemotherapy offers an overall survival advantage of only 9% at 12 months compared with supportive care (25). Two-drug chemotherapy (doublets) appears to be superior to either a single agent or three-drug combinations (26). Cisplatin-based doublets are associated with a marginal one-year survival benefit compared with platinum-free regimens (27). Platinum-free regimens can be given as an alternative especially in patients who cannot tolerate platinum-based treatment (24). Although gemcitabine, vinorelbine, paclitaxel or pemetrexed are often added to either cisplatin or carboplatin, the choice of the second drug does not appear to matter in increasing survival (28).

Targeted Therapies

Starting in the early 2000s, NSCLC subtypes have evolved from being histologically described to molecularly defined. The use of targeted therapies in lung cancer based on molecular markers is a very rapidly changing field. At the time this article was being written (February 2018) the information was current but recommended therapies are likely to change with development of new therapies and research. It is important to point out that despite these advances, there remains no cure for stable IV NSCLC. Table 2 represents a summary of targets and targeted therapy along with the American Society of Clinical Oncology (ASCO) recommendations for stage IV NSCLC as of February 2018 (24).

Table 2. Targets and targeted therapies for NSCLC (24).

*Currently not recommended for clinical use by ASCO.

The need for adequate tissue to perform molecular studies creates challenges for pulmonologists doing bronchoscopic procedures. Whereas it was previously adequate to obtain diagnostic material. However, it is now important to obtain adequate tissue to perform additional molecular testing to allow determination of whether targeted therapies are appropriate. Sometimes tissue is inadequate which might necessitate a second procedure if clinically warranted.  

Vascular Growth Factors

Epidermal Growth Factor Receptor (EGFR). The EGFR pathway represents the pioneer of personalized medicine in lung cancer. EGFR is a transmembrane receptor that is highly expressed by some NSCLCs. Binding of ligands (epidermal growth factor, tumor growth factor-alpha, betacellulin, epiregulin or amphiregullin) to the extracellular EGFR domain results in autophosphorylation through tyrosine kinase activity (29). This initiates an intracellular signal transduction cascade that affects cell proliferation, motility and survival (29). Inhibition of ligand and EGFR binding or the activation of tyrosine kinases inhibit the downstream pathways resulting in inhibition of cancer cell growth (29).

Initial studies showed that most patients with NSCLC had no response to the tyrosine kinase inhibitor (TKI), gefitinib, which targets phosphorylation of EGFR (30). However, about 10 percent of patients had a rapid and often dramatic clinical response (30). An explanation for these results occurred with the identification of mutations of the tyrosine kinase coding domain (exons 18–21) of the EGFR gene. Subsequent research linked these mutations to the clinical response to gefitinib (31,32). Although about 10% of Caucasian NSCLC have these mutations, the mutations were observed more commonly in Asian patients, particularly non-smoking women (33). There is now overwhelming and consistent evidence from multiple trials that all the approved EGFR-TKIs (gefitinib, erlotinib, or afatinib) have greater activity than platinum-based chemotherapy as the first-line treatment of patients with advanced NSCLC with activating EGFR mutations (24).  These agents have more favorable toxicity profiles than platinum-based chemotherapy and have demonstrated improvements in quality of life. The choice of which EGFR-TKI to recommend to patients should be based on the availability and toxicity of the individual therapy. Randomized clinical trials are ongoing comparing EGFR-TKIs. The results of these trials may help refine this in the future.

Despite high tumor response rates with first-line EGFR-TKIs, NSCLC progresses in a majority of patients after 9 to 13 months of treatment. At the time of progression, approximately 60% of patients (regardless of race or ethnic background) are found to have a Thr790Met point mutation (T790M) in the gene encoding EGFR (34). The presence of the T790M variant reduces binding of first-generation EGFR-TKIs to the leading to disease progression (34). Osimertinib is an irreversible EGFR-TKI that can bind to EGFR despite the T790M resistance mutations and has recently become clinically available (35). Currently it is recommended for T790M mutations that occur after the first-line EGFR-TKIs have failed (24).

Cetuximab is a monoclonal antibody directed against EGFR itself. In the past, addition of cetuximab to cisplatin doublet chemotherapy in EGFR positive tumors was usual. However, cetuximab has recently been shown to shorten progression free survival with some adverse effects and is no longer recommended (24).

Vascular endothelial growth factor (VEGF). Angiogenesis, the formation of new blood vessels, is a fundamental process for the development of solid tumors and the growth of secondary metastatic lesions. Vascular endothelial growth factor (VEGF) acts to promote normal and tumor angiogenesis. Bevacizumab, a recombinant, humanized, monoclonal antibody against VEGF, was previously recommended as first-line therapy in stage IV NSCLC patients without a contraindication. However, the most recent ASCO guidelines finds insufficient evidence to recommend bevacizumab in combination with chemotherapy as first-line treatment (24).

Other Kinase Inhibitors. Receptor tyrosine kinase 1 (ROS1) and the structurally similar anaplastic lymphoma kinase (ALK) are enzymes that are critical regulators of normal cellular activity. In NSCLC rearrangements of these genes can cause them to act as oncogenes, or genes that transform normal cells into cancer cells. Rearrangements in the ROS1 or ALK genes are found in a small percentage of patients with NSCLC. Crizotinib is a molecule that blocks both the ROS1 and ALK proteins. Crizotinib reduced tumor size in ALK+ or ROS1+ positive patients although the most recent ASCO guidelines consider the evidence only moderate with ALK+ and weak with ROS1+ patients (24,36-8).

Checkpoint Inhibitors. An important part of the immune system is its ability to tell the difference between normal cells and those that are “foreign”. To do this, it uses “checkpoints”, molecules on certain immune cells that need to be activated (or inactivated) to start an immune response (39). NSCLC can use these checkpoints to avoid being attacked by the immune system. Programmed cell death protein 1 (PD-1) is a checkpoint protein on T cells. It normally acts as an “off switch” when it attaches to programmed death-ligand 1 (PD-L1), a protein on some normal (and cancer) cells. Some NSCLCs have large amounts of PD-L1, which helps them evade immune attack. Monoclonal antibodies that target either PD-1 or PD-L1 can block this binding and boost the immune response against NSCLC cells. In patients with NSCLC with >50% of their tumor cells PD-1+ (tumor proportion score >50%), pembrolizumab, a monoclonal antibody against PD-1, significantly prolonged progression-free and overall survival compared to platinum-based chemotherapy (40). Based on this trial, pembrolizumab is now recommended by ASCO for patients with a tumor proportion score >50% for PD-1 (23). A number of other PD-1 (e.g., nibolumab) and PD-L1 inhibitors (e.g., atezolizumab, avelumab, durvalumab) exist but ASCO recommends only pembrolizumab at this time (39,40). As more of these checkpoint inhibitors are developed and tested this will likely change.

Second and Third-Line NSCLC Therapy

Second and third-line therapy for NSCLC is beyond the scope of this brief review. It is a rapidly evolving field which should include close collaboration between the pulmonologist, oncologist and other members of the patient’s NSCLC treatment team.

After an initial response, lung cancers can become resistant to therapy. One example mentioned above is the development of the T790M mutation in EGFR+ NSCLC.  In selected instances rebiopsy of the primary tumor or metastases can direct a new, effective therapy. Obviously, it is not possible to rebiopsy every NSCLC patient after failure of the initial therapy. However, other techniques are being investigated. One is liquid biopsy where blood is drawn and subjected to molecular techniques to determine a possible cause for tumor resistance.  Multiple liquid biopsy molecular methods are presently being examined to determine their efficacy as surrogates to the tumor tissue biopsy (41).

Future Directions

The combination of a variety of existing therapies for NSCLC is being evaluated. These will likely yield revised recommendations for therapy. In addition, a variety of therapies, both existing for other cancers, or newer therapies in development are being tested.  These include both monoclonal antibodies and biologic inhibitors (Table 3).

Table 3. Potential new targeted therapies for NSCLC (42,43).

The numbers of pathways and drugs being tested is very impressive and the clinical responses can be dramatic in some patients. One might be tempted to conclude that these therapies might result in a “cure” for NSCLC. However, most of these mutations occur in a small minority of NSCLCs. Furthermore, even if initially successful, resistance to targeted therapies may quickly develop limiting their clinical usefulness in NSCLC.

Targeted therapies may also have potential as adjuvant therapies. In support of this concept, a recent phase 3 study compared durvalumab as consolidation therapy with placebo in patients with stage III NSCLC who did not have disease progression after two or more cycles of platinum-based chemoradiotherapy (44). The progression-free survival was 16.8 months with durvalumab versus 5.6 months with placebo (p<0.001). It seems likely that more trials using targeted therapy earlier in cancer therapy will be done.

References

1. American Cancer Society. Key statistics for lung cancer. 2016. Available at: https://www.cancer.org/cancer/non-small-cell-lung-cancer/about/key-statistics.html (accessed 2/17/18).
2. The Health Consequences of Smoking-50 Years of Progress: A Report of the Surgeon General, US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, Washington, DC, 2016. Available at: https://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf (accessed 2/17/18).
3. American Cancer Society. What Is non-small cell lung cancer? 2016. Available at: https://www.cancer.org/cancer/non-small-cell-lung-cancer/about/what-is-non-small-cell-lung-cancer.html (accessed 2/17/18).
4. American Cancer Society. Targeted therapy drugs for non-small cell lung cancer. June 23, 2017. Available at: https://www.cancer.org/cancer/non-small-cell-lung-cancer/treating/targeted-therapies.html (accessed 2/17/18).
5. National Cancer Institute. Non-small cell lung cancer treatment (PDQ®)–health professional version: Stage information for NSCLC. February 1, 2018. Available at: https://www.cancer.gov/types/lung/hp/non-small-cell-lung-treatment-pdq#section/_470 (accessed 2/19/18).
6. National Cancer Institute. Non-small cell lung cancer treatment (PDQ®)–health professional version: Treatment option overview for NSCLC. February 1, 2018. Available at: https://www.cancer.gov/types/lung/hp/non-small-cell-lung-treatment-pdq#section/_4889 (accessed 2/19/18).
7. Howington JA, Blum MG, Chang AC, Balekian AA, Murthy SC. Treatment of stage I and II non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143(5 Suppl):e278S-e313S. [CrossRef] [PubMed]
8. Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg. 1995;57(3):615-22. [CrossRef] [PubMed]
9. Flores RM, Park BJ, Dycoco J, et al. Lobectomy by video-assisted thoracic surgery (VATS) versus thoracotomy for lung cancer. J Thorac Cardiovasc Surg. 2009 Jul;138(1):11-8. [CrossRef] [PubMed]
10. Rowell NP, Williams CJ. Radical radiotherapy for stage I/II non-small cell lung cancer in patients not sufficiently fit for or declining surgery (medically inoperable): a systematic review. Thorax. 2001;56(8):628-38. [CrossRef] [PubMed]
11. Rowell NP, Williams CJ. Radical radiotherapy for stage I/II non-small cell lung cancer in patients not sufficiently fit for or declining surgery (medically inoperable). Cochrane Database Syst Rev. 2001;(2):CD002935. [CrossRef] [PubMed]
12. Abreu CE, Ferreira PP, de Moraes FY, Neves WF Jr, Gadia R, Carvalho Hde A. Stereotactic body radiotherapy in lung cancer: an update. J Bras Pneumol. 2015 Jul-Aug;41(4):376-87. [CrossRef] [PubMed]
13. Tandberg DJ, Tong BC, Ackerson BG, Kelsey CR. Surgery versus stereotactic body radiation therapy for stage I non-small cell lung cancer: A comprehensive review. Cancer. 2018 Feb 15;124(4):667-78. [CrossRef] [PubMed]
14. Cortés AA, Urquizu LC, Cubero JH. Adjuvant chemotherapy in non-small cell lung cancer: state-of-the-art. Transl Lung Cancer Res. 2015 Apr;4(2):191-7. [CrossRef] [PubMed]
15. PORT Meta-analysis Trialists Group. Postoperative radiotherapy in non-small-cell lung cancer: systematic review and meta-analysis of individual patient data from nine randomised controlled trials. Lancet. 1998;352(9124):257-63. [CrossRef] [PubMed]
16. Burdett S, Stewart L. Postoperative radiotherapy in non-small-cell lung cancer: update of an individual patient data meta-analysis. Lung Cancer. 2005;47(1):81-3. [CrossRef] [PubMed]
17. Mayer R, Smolle-Juettner FM, Szolar D, et al. Postoperative radiotherapy in radically resected non-small cell lung cancer. Chest. 1997;112(4):954-9. [CrossRef] [PubMed]
18. Dautzenberg B, Arriagada R, Chammard AB, et al. A controlled study of postoperative radiotherapy for patients with completely resected nonsmall cell lung carcinoma. Cancer. 1999;86(2):265-73. [CrossRef] [PubMed]
19. Feng QF, Wang M, Wang LJ, et al. A study of postoperative radiotherapy in patients with non-small-cell lung cancer: a randomized trial. Int J Radiat Oncol Biol Phys. 2000;47(4):925-9. [CrossRef] [PubMed]
20. Douillard JY, Rosell R, De LM, et al. Adjuvant vinorelbine plus cisplatin versus observation in patients with completely resected stage IB-IIIA non-small-cell lung cancer (Adjuvant Navelbine International Trialist Association [ANITA]): a randomised controlled trial. Lancet Oncol. 2006;7(9):719-27. [CrossRef] [PubMed]
21. Ramnath N, Dilling TJ, Harris LJ, et al. Treatment of stage III non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013 May;143(5 Suppl):e314S-e340S. [CrossRef] [PubMed]
22. van Meerbeeck JP, Kramer GW, Van Schil PE, et al. Randomized controlled trial of resection versus radiotherapy after induction chemotherapy in stage IIIA-N2 non-small-cell lung cancer, J Natl Cancer Inst. 2007;99(6):442-50. [CrossRef] [PubMed]
23. Albain KS, Swann RS, Rusch VW, et al. Radiotherapy plus chemotherapy with or without surgical resection for stage III non-small-cell lung cancer: a phase III randomised controlled trial. Lancet, 2009;374(9687):379-86. [CrossRef] [PubMed]
24. Hanna N, Johnson D, Temin S, et al. Systemic therapy for stage IV non–small-cell lung cancer: American Society of Clinical Oncology clinical practice guideline update J Clin Oncol. 2017;35:3484-515. [CrossRef] [PubMed]
25. NSCLC Meta-Analyses Collaborative Group. Chemotherapy in addition to supportive care improves survival in advanced non-small-cell lung cancer: a systematic review and meta-analysis of individual patient data from 16 randomized controlled trials. J Clin Oncol. 2008 Oct 1;26(28):4617-25. [CrossRef] [PubMed]
26. Lilenbaum RC, Herndon JE, List MA, et al. Single-agent versus combination chemotherapy in advanced non-small-cell lung cancer: the cancer and leukemia group B (study 9730), J Clin Oncol. 2005;23(1):190-6. [CrossRef] [PubMed]
27. Delbaldo C, Michiels S, Syz N, et al. Benefits of adding a drug to a single-agent or a 2-agent chemotherapy regimen in advanced non-small-cell lung cancer: a meta-analysis. JAMA. 2004;292(4):470-84. [CrossRef] [PubMed]
28. Schiller JH, Harrington D, Belani CP, et al. Comparison of four chemotherapy regimens for advanced non-small-cell lung cancer, N Engl J Med. 2002;346(2):92-8. [CrossRef] [PubMed]
29. Citri A, Yarden Y. EGF-ERBB signalling: towards the systems level. Nat Rev Mol Cell Biol. 2006;7(7):505-16. [CrossRef] [PubMed]
30. Kris MG, Natale RB, Herbst RS, et al. Efficacy of gefitinib, an inhibitor of the epidermal growth factor receptor tyrosine kinase, in symptomatic patients with non-small cell lung cancer: a randomized trial. JAMA. 2003;290:2149-58. [CrossRef] [PubMed]
31. Lynch TJ, Bell DW, Sordella R, et al. Activating mutations in the epidermal growth factor receptor underlying responsiveness of non-small-cell lung cancer to gefitinib. N Engl J Med. 2004;350(21):2129-39. [CrossRef] [PubMed]
32. Paez JG, Jänne PA, Lee JC, et al. EGFR mutations in lung cancer: correlation with clinical response to gefitinib therapy. Science. 2004;304(5676):1497-500. [CrossRef] [PubMed]
33. Hirsch FR and Bunn PA Jr. EGFR testing in lung cancer is ready for prime time. Lancet Oncol. 2009;10(5):432-3. [CrossRef] [PubMed]
34. Kobayashi S, Boggon TJ, Dayaram T, et al. EGFR mutation and resistance of non–small-cell lung cancer to gefitinib. N Engl J Med. 2005;352:786-92. [CrossRef] [PubMed]
35. Mok TS, Wu YL, Ahn MJ, et al. Osimertinib or platinum-pemetrexed in EGFR T790M-positive lung cancer. N Engl J Med. 2017;376:629-40. [CrossRef] [PubMed]
36. Shaw AT, Kim DW, Nakagawa K, et al. Crizotinib versus chemotherapy in advanced ALK-positive lung cancer. N Engl J Med. 2013;368(25):2385-94. [CrossRef] [PubMed]
37. BJ Solomon, T Mok, DW Kim, et al. First-line crizotinib versus chemotherapy in ALK-positive lung cancer N Engl J Med 2014;371(23):2167-77. [CrossRef] [PubMed]
38. Goto K, Chih-Hsin Yang J, Kim DW: Phase II study of crizotinib in east Asian patients (pts) with ROS1-positive advanced non–small cell lung cancer (NSCLC). J Clin Oncol. 2016; 34:(suppl; abstr 9022).
39. American Cancer Society. Immune checkpoint inhibitors to treat cancer. May 1, 2017. Available at: https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/immunotherapy/immune-checkpoint-inhibitors.html (accessed 2/19/18).
40. Reck M, Rodrıguez-Abreu D, Robinson AG, et al. Pembrolizumab versus chemotherapy for PDL1-positive non–small-cell lung cancer. N Engl J Med. 2016;375:1823-33. [CrossRef] [PubMed]
41. Ansari J, Yun JW, Kompelli AR, et al. The liquid biopsy in lung cancer. Genes Cancer. 2016 Nov;7(11-12):355-67. [CrossRef] [PubMed]
42. Cortinovis D, Abbate M, Bidoli P, Capici S, Canova S. Targeted therapies and immunotherapy in non-small-cell lung cancer. Ecancer. 2016;10:648-75. [CrossRef] [PubMed]
43. Silva AP, Coelho PV, Anazetti M, Simioni PU.Targeted therapies for the treatment of non-small-cell lung cancer: Monoclonal antibodies and biological inhibitors. Hum Vaccin Immunother. 2017 Apr 3;13(4):843-53. [CrossRef] [PubMed]
44. Antonia SJ, Villegas A, Daniel D, et al. Durvalumab after Chemoradiotherapy in Stage III Non-Small-Cell Lung Cancer. N Engl J Med. 2017 Nov 16;377(20):1919-29. [CrossRef] [PubMed]

Cite as: Robbins RA, Kummet TD. First-line therapy for non-small cell lung cancer including targeted therapy: A brief review. Southwest J Pulm Crit Care. 2018;16(3):157-67. doi: https://doi.org/10.13175/swjpcc038-18 PDF 

March 2018 Pulmonary Case of the Month

Thomas D. Kummet, MD

Sequim, WA USA

Pulmonary Case of the Month CME Information

Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity. 

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Thomas D. Kummet, MD.  All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity.

Learning Objectives: As a result of completing this activity, participants will be better able to:

1. Interpret and identify clinical practices supported by the highest quality available evidence.
2. Establish the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Translate the most current clinical information into the delivery of high quality care for patients.
4. Integrate new treatment options for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at Banner University Medical Center Tucson

Current Approval Period: January 1, 2017-December 31, 2018

Financial Support Received: None

History of Present Illness

The patient was a 62-year-old woman who complained of a sudden severe increase in a three-month history of mild left upper extremity pain. 

PMH, SH and FH

The patient had no significant past medical history. She is a non-smoker. Family history is non-contributory.

Physical Examination

• Vital Signs: Pulse 102 beats/min, blood pressure 140/84 mm Hg, respirations 16 breaths/min, Temperature 37.4º C, SpO2 94% on room air.
• Lungs: Clear.
• Heart: Regular rhythm.
• Abdomen: without organomegaly, masses or tendernesses.
• Extremities: Both upper extremities were unremarkable. The left shoulder had a full range of motion. Pulses were intact bilaterally and equal.
• Neurologic: Upper extremity strength was good and equal. Light touch and pin prick were intact. Deep tendon reflexes were well preserved.

Which of the following are indicated in management at this time? (Click on the correct answer to proceed to the second of seven pages)

1. Reassurance that the pain will improve
2. Shoulder x-ray
3. Treatment with oxycodone
4. 1 and 3
5. All of the above

Cite as: Kummet TD. March 2018 pulmonary case of the month. Southwest J Pulm Crit Care. 2018;16(3):110-6. doi: https://doi.org/10.13175/swjpcc033-18 PDF